Breastfeeding Article: Utilizing the Breastfeeding Pathway Model to Help NICU Mothers and Babies Breastfeed

For my Breastfeeding Educator Certification I had to write an article on a topic related to breastfeeding. I chose to write about breastfeeding in the NICU because of the pressure I felt as I was breastfeeding my oldest during his stay in a Level IV NICU. 

Breastfeeding in a Neonatal Intensive Care Unit (NICU) can be extremely challenging. Not only does the baby have a serious condition that requires specialized medical care, but the practices of NICU’s may not be conducive to establishing breastfeeding. Strict schedules for feeding, medications for the baby and the baby being attached to several monitors can all make it difficult for the mother and baby to work out a breastfeeding relationship that can work effectively during hospitalization and after the baby is released.

Mothers are often under pressure to get breastfeeding perfect right away and that pressure often increases for the mother of a baby in the NICU since her baby must meet certain weight gain requirements before he can be released from the NICU. Doctors in NICU’s are often supportive of breastmilk as a medicine, but actual feeding from the breast are often not perceived as a high priority for the baby’s care, especially long term (Lieberman).

Because of the difficulties with breastfeeding, the rates of breastfeeding for NICU babies are often lower than the national average- which is far lower than ideal to begin with. The rates for infants receiving any breast milk at some point range from about 50% to 83%. However, those rates drop as the babies are released from the hospital. Studies have found that the rates of breast milk feeds at discharge are 64%, with the rate of breastfeeding being 38%. One study found that at 4 months of age, only 24% of infants born at less than 33 weeks gestation continue to receive some breast milk feedings. (Pineda, 8). Without a strategy to plan for long term breastfeeding, many mothers end up providing breastmilk through pumping during their baby’s hospital stay and struggling to breastfeed afterwards- if they breastfeed at all.

However, University of California San Diego Medical Center has instituted a Breastfeeding Pathway program to help mothers not only provide breastmilk in the NICU, but also establish long term breastfeeding for mothers and infants. The approach is somewhat novel. Instead of viewing breastfeeding as an event that may or may not happen, the Breastfeeding Pathway focuses on establishing breastfeeding in a step-by-step fashion while the mother is pumping.

The first step is to encourage skin-to-skin contact as much as possible as soon as the baby is stable. The next step is to establish non-nutritive sucking by getting the baby to suck as much as possible even if he is receiving little or no milk. Step three moves to nutritive breastfeeding where the baby starts taking feedings at the breast. Step four is bottle and breastfeeding where the mother provides feedings whenever she is at the baby’s bed side, and bottle feeding is utilized when she is not present.

Step five involves planning for breastfeeding after discharge. The mother is advised about ongoing pumping needs and how to transition towards breastfeeding as much as possible. The hospital also maintains a Premature Infant Nutrition Clinic to help mother continue the transition to breastfeeding.

The results for the Breastfeeding Pathway have been excellent. 82 percent of UCSD’s NICU babies are receiving breastmilk either at the breast or from a bottle at discharge. Of their infants under 1500 grams, 75 percent are receiving some amount of breastmilk at discharge. With the Breastfeeding Pathway program in place, the hospital has seen an increasing number of mothers getting their babies to the breast several times a day instead of several times a week (Stellwagen). Unfortunately, not every mother who has a baby in the NICU has so much support from the hospital.

Doulas and lactation consultants can utilize the principles of the Breastfeeding Pathway model with NICU mothers and babies to help. Most NICU’s permit or encourage Kangaroo Care to some degree and encouraging mothers to hold their babies skin-to-skin as much as possible under their particular circumstances is one of the best ways to start breastfeeding a baby in NICU. While the mother is pumping milk for her baby, she can still put him to the breast, first for non-nutritive sucking and then for nutritive sucking. As the mother and the baby fall into a pattern of successful breastfeeding, working with the mother and the hospital staff to encourage more feedings at the breast will help build both the mother and baby’s confidence and set the stage for breastfeeding after discharge.

Typically, the parents and baby are often under a great deal of stress making the move from NICU to home. The baby may require special care or may be on medications. Unfortunately, most hospitals do not have the kind of post-discharge support that UC San Diego provides for it’s NICU mothers and babies. Again, this is where doulas and other birth and breastfeeding helpers can step in with the Breastfeeding Pathways model. As discharge nears, the parents and their doula or lactation consultant can request to work out a plan for breastfeeding post discharge in consultation with the baby’s team of specialists and doctors.

The parents should receive contact information with local breastfeeding support services including WIC, the La Leche League, breastfeeding hotline numbers, lactation consultants, doulas who specialize in breastfeeding and any other resources available. Making sure that the parents don’t feel abandoned after discharge and know they have help available to them will go a long way towards helping ease the transition from the NICU into breastfeeding at home.

Works Cited

Liberman, Tanya. “Booby Traps Series: Booby Traps in the NICU.” Best For Babes. Retrieved from http://www.bestforbabes.org/booby-traps-series-booby-traps-in-the-nicu/Accessed 16 August 2016.

Pineda, Gittens Roberta. “Breastfeeding Practices In The Neonatal Intensive Care Unit Before And After An Intervention Plan.” University of Florida Department of Rehabilitation Science. August 2006, p. 8. Retrieved from ufdcimages.uflib.ufl.edu/UF/E0/01/56/59/00001/pineda_r.pdf. Accessed 15 August 2016.

University of California San Diego Medical Center. “Breastfeeding Pathway for All Mothers and Infants.” Accessed 17 August 2016 health.ucsd.edu/specialties/obgyn/maternity/newborn/nicu/spin/staff/Documents/Riley%2520BF%2520Pathway%2520NICU.docx+&cd=1&hl=en&ct=clnk&gl=us

Stellwagen, Lisa. “Re: Statistics on Breastfeeding Pathway?” Received by Nicholette Lambert, 18 August 2016.

Rethinking How We Approach The Abortion Debate

My views on the abortion debate- not so much the procedure itself- changed forever when I found out that a friend of mine had an abortion. She had been engaged and was pregnant when she found out that her boyfriend was cheating on her, using drugs and had a criminal history. She wanted to place the baby for adoption, but the slimeball said he wouldn’t give up parental rights and would get custody of the child.

She didn’t know that his claim to custody and/or visitation would have been on shaky grounds since he had a criminal record and history of drug use. She felt that she had only two options: end the pregnancy or leave a child in the hands of a dangerous person. She chose abortion, but it grieved her deeply. Later on, her friends, not knowing of her experience, would share things on Facebook condemning women who had an abortion as murderers who cared only for their own convenience and it would open up the wound all over again.

The abortion debate is an extremely heated one and I think it’s very common for people from different sides to characterize things in an extremely narrow way. I guess what I would like to propose is that as deep as our feelings run on this issue, that we all try to look at the issue with more understanding of different points of view. In short, I think we need more compassion from everyone. I would like to suggest the following shifts in the way we approach the issue of abortion:

Move beyond the issue of legality– Laws only prevent things from happening to a limited extent. We have laws against a lot of things- speeding, sexual abuse, child pornography, murder, insider trading, etc. and those things still happen. The same is true of abortion.

Before Roe vs. Wade, women still had abortions. In the 18th century, recipes for herbal preparations that could act as abortifacients were known and used. The medical profession’s relationship with the procedure has been complicated. While the AMA took an anti-abortion stance publicly during the 19th century, many doctors continued to offer the procedure- often competing with midwives. Some estimates place the per capita number of abortions in the Victorian era to be seven or eight times as high as it is today. In the 20th century, abortions were still harder to obtain since many doctors didn’t want to be prosecuted under abortion laws, but many women did- sometimes at their own risk. Illegal abortions were often performed in unsafe conditions leading to 5,000 deaths a year. If Roe vs. Wade was appealed, it would not stop women from seeking abortions or being pressured into them. If we’re looking to preserve life and prevent abortion it is going to happen through choices on an individual level, not through legislation.

Understand why women have abortions– The motives for abortion often seem to get reduced down to soundbites about “rights” and “murder”. This isn’t getting anyone anywhere because these two concepts vastly oversimplify the dynamic and don’t address the reasons why women often feel an abortion is a better choice than carrying a pregnancy to term. One of the more detailed studies from 2005 on the subject found some interesting results. This was especially intriguing because it compared the reasons for abortion in 1987 vs. 2005. One of the interesting things that this study found was that “timing is wrong/ not ready to be a parent yet” was still the most common reason cited for having an abortion, but one reason had increased dramatically was “Had completed childbearing/ had grown children”.

Since 1987, fewer women were having abortions because they felt it would interfere with their careers, but slightly more were having an abortion because they felt that it would interfere with school. (This is ironic because more schooling has been moving online since the widespread use of the internet.) Finances was another frequently cited reason. Interestingly, about 40% of women  in this study said they had considered adoption, but felt it was morally wrong to give a baby away.

Stop catastrophizing pregnancy– I remember when I was a teenager, it seemed like all of the stuff in my child development class focused on how having a baby young would be a disaster. It would be expensive and would condemn a girl to a life of poverty. It would also be horribly uncomfortable and difficult. I even saw religious groups get in on the act, talking about how terrible it would be to have sex and then get pregnant. Now personally, if my daughter were to get pregnant as a teenager, I wouldn’t exactly be thrilled, but there are far worse things your kid could become (sex predator, terrorist, gang member, scam artist, white collar criminal…). I don’t have any concrete data on this, but I think if we were to stop telling our children that unplanned pregnancy is the worst thing that could happen, we might find that women feel like there are options available to them if they do get pregnant. I don’t think that being honest about the realities and options associated with single motherhood like job opportunities and education options is glorifying young single motherhood, but it is one option. I think that women need an honest view of pregnancy and motherhood that doesn’t reduce it to either easy or a travesty.

Stop castrophizing labor– Again, I don’t have any hard labor here, but I’m trying to put myself into the shoes of the average woman who doesn’t know that labor isn’t an automatic trauma. If you believe that labor is going to be this horribly frightening, painful thing and even life-threatening thing that you have to go through to get a baby, you’re not going to feel very inclined to go through it unless you really want that baby and are going to have it be yours. Labor is hard work-hard work. But it can have dignity, peace and love. The subject of labor and birth support for biological mothers is something rarely discussed, but I think more doulas and midwives should offer their services to women who plan to place a child for adoption and share their experiences about attending these kinds of births.

Have a more open dialogue about adoption– Families and adult adopted children  who feel positively about adoption should feel free to share their stories as a way of reducing the stigma associated with choosing adoption for a baby. I think there should be more resources explaining the options for different kinds of adoptions (varying degrees of open to closed) and the rights of birth parents. More information can help people make more informed decisions.

 

 

 

 

Breastfeeding Is a Weed, Not an Orchid

Sometimes I get the impression that people think breastfeeding is like a rare orchid that can only bloom under the most precise conditions. Like in order to successfully breastfeed you have to be a middle-class white woman who doesn’t work outside the home with a full-term, singleton pregnancy and uncomplicated natural birth of a baby who has no problems.

This is, in fact, false. Breastfeeding is like a dandelion. It’s misunderstood but actually incredibly useful and it’s everywhere. (Dandelions are edible, the greens are highly nutritious and you can even make a tea from the roots.)

From Inuit to Australian Aboriginal, mothers all over the world

have been breastfeeding their babies for millennia. Aristocrats, nomads, farmers, and hunter-gatherer mothers have all breastfed their babies.

Throughout history, women breastfed their babies under all kinds of circumstances. If you look at the background of this painting of Mormon handcart pioneers, you can see a mother nursing her infant.

Breastfeeding has saved the lives of babies in some of the most dire circumstances like a few of the babies who were born in Auschwitz. Barbara Puc‘s mother was unable to breastfeed her after being sick and malnourished, but another woman at Auschwitz who had just lost a baby was lactating and nursed the little baby girl- saving the baby’s life in a place where infant formula was an impossibility.

Women have been breastfeeding twins, siblings and even premature babies all before formula was widely available.

From a biological perspective, it’s actually abnormal for only 22.3% of babies to be exclusively breastfed for six months. But because it’s so rare for a baby to be breastfed according to biological norms, it gives the illusion that breastfeeding is like that rare orchid that blooms only in a climate-controlled greenhouse. Don’t be fooled. Breastfeeding is like those hearty dandelions that are edible and nutritious and can be extraordinarily prolific.

 

The Butlerian Jihad and Maternal Health

Frank Herbert’s epic sci-fi novel Dune chronicles humanity’s interstellar civilization thousands of years into the future. (If you read it, you’ll notice more than a few similarities between Dune  and Star Wars: A New Hope. George Lucas was very inspired by Dune and his initial versions of Star Wars were more of a reworking of it. Once he used a little more Force and a little less spice, the whole thing really took off.)

Anyway, in Herbert’s imagined human history of the future, there is at one point something called the Butlerian Jihad. Humans developed robots to do lots of things for them and became so cognitively lazy that the robots made the humans slaves for 900 years. Eventually, the humans got smart enough to realize that they didn’t need robots for everything, rose up and did away with the them. After that, specially trained humans called Mentats did all the computing. I think we’ve hit a similar problem with maternal health.

We have interventions of all kinds for giving birth- inductions, pain medication, cesareans, forceps, vacuum extraction. Formula feeding has changed the landscape of infant feeding in a single century. And I think we have become (in general) too dependent on them.

For example, I’ve encountered women who say, “I could never give birth without an epidural”. Well, if you were stranded by the side of the road en route to the hospital in late stage labor, your baby would come with or without an epidural! Women have been going into spontaneous labor for thousands of years and human biology has not changed to need the use of inductions on a regular basis. Ditto for c-sections. The vast majority our ancestors breastfed their babies, because babies who weren’t breastfed had a very slim chance of survival up until recently in human history.

Frank Herbert envisioned a universe without robots, but I don’t see a world without medical interventions for birth. When they are truly necessary, medical interventions can save lives. But like the inhabitants of the Dune universe, there is danger in becoming so overly reliant on technology that we give up our part. Medical interventions have side effects and when used on mothers and babies who don’t need them, they don’t do any good and can do harm.

And so, I propose that it is time that we institute our own personal maternal and child health Butlerian Jihad. It’s time to put medical intervention in its place as a measure for real emergencies and understand that our bodies are generally capable. For the vast majority of pregnancies, it is completely normal for a woman to go into spontaneous labor, deliver a baby vaginally (even without pain medication) and breastfeed the baby thereafter. Millions of years of biology are on our side.

Shaken Baby Syndrome: A Public Health Issue Looking For Evidence

Have you ever noticed that parents get an awful lot of education about Shaken Baby Syndrome? We’re told all the time never to shake our babies- though any other form of abuse is rarely talked about. Have you ever stopped to ask why shaking is such an issue rather than just child abuse in general? It’s actually a rather strange story.

Shaken Baby Syndrome as an accepted pathology and its accompanying prevention campaigns were not the result of several repeatable studies on a large number of human infants displaying the “triad” of SBS symptoms (subdural and retinal hemorrhage with brain swelling) after confirmed child abuse. Instead, it began with monkeys and simulated motor vehicle collisions.

These experiments were conducted in 1968 on rhesus monkeys subjected to simulated motor vehicle collisions at speeds of 40 miles per hour. 15 of the 19 monkeys were found to have a “triad” of symptoms (subdural and retinal hemorrhage and brain swelling) after the experiments. From these observations (and without any further independent investigation), American radiologist John Caffey and British neurosurgeon Norman Guthkelcher theorized that human infants could develop a similar condition if deliberately and violently shaken.

Since infants displaying subdural hematoma with retinal hemorrhage  (bleeding in the brain and behind the eyes) frequently did not show any signs of head injury or abuse, Caffey and Guthkelcher proposed that the shaking must have occurred in secret with no other witnesses. This theory was not consistent with a significant and well-established body of literature which showed that subdural hematoma, retinal hemorrhage and brain swelling could occur without impact to the head or shaking, but it was published and subsequently became very popular at many conferences aimed at law enforcement, social services and physicians. Actually, a review of the literature on child abuse from 1966 through 1998 showed significant weaknesses in SBS literature. There are no published controlled prospective trials with replicated studies on the condition (Gabaeff, 2011). In other words, people started believing SBS was real simply because they heard about it so much from sources they thought were trustworthy.

Current research has shown the theories behind SBS to be highly questionable. An experiment with dummies that mimicked the size and weight of human infants with sensors attached throughout showed that shaking would not cause the type of acceleration which would produce a subdural hematoma in a human infant. Other inconsistencies with SBS are that experts admit that bruises on the baby’s arms and torso that would normally be expected in a baby subjected to excessive force are mostly absent from SBS cases. Which begs the question, how can a baby be shaken so hard that it induces brain damage, but not bruising?

Shaken Baby Syndrome was once unchallenged in the medical community. But lately it has been under greater scrutiny- especially with more parents and caretakers being tried for murder and attempted murder with an SBS diagnosis though they maintain their innocence. And with this greater scrutiny a more complicated picture is emerging.

For example, certain vitamin deficiencies and encephalopathy are known to cause the triad of SBS symptoms. Because  of this, more physicians are testifying for the defense on behalf of parents and caretakers that shaking is not the only cause of the symptoms seen in the baby. (Many defense experts for SBS will charge on a sliding scale because they know that a public defender won’t have the expertise to provide an adequate and informed defense.)

Another problems comes from a behavioral perspective. Some people accused of shaking a baby have no history of violent behavior. In one case highlighted in the New York Times, the daycare worker convicted of shaking a two month old baby had cared for her own children and several others including an autistic boy and a girl with one arm without any history of violent behavior. The other daycare workers described her as a very patient and gentle person. Many cases of SBS ask us to assume that people without any history of abusive or violent behavior and who have frequently raised their own children without any abuse suddenly shake a baby to death or brain damage out of the blue. And then other cases involve clear cut abuse where shaking wasn’t the only form of abuse involved.

SBS proponents frequently point out that the diagnosis still holds up because they have confessions from parents and caretakers as  evidence. However, these confessions are not very clear representations of the situation. Some parents said they had shaken the baby in a non-aggressive way to try to revive it after finding the infant unconscious and not breathing.  Others admitted to shaking, but only in a more generalized way as one of many abusive actions against the baby, so it may not have been shaking that actually caused the death.

Others have been told point blank by law enforcement and medical experts that the police and doctors know the accused is guilty and that he or she will no chance at acquittal in a trial since doctors and scientists will testify that there is no other way the baby could have died than at the hands of the accused. Sometimes they’re are offered a plea bargain and told it is the only way they will escape a lifetime in prison, so they confess. The New York Times highlights the case of a daycare worker from Peru for whom English was a second language who was interrogated in English, not Spanish, another thing that could “muddy the waters”.

For me, I believe in the power of public health as a field of study and as a tool for making the world a better place. Many of the things we’re doing to promote public health have solid evidence like eating a healthy diet, exercise, smoking cessation, seat belts and the list can go on and on. But Shaken Baby Syndrome simply doesn’t have the evidence the back it up as a public health problem.

Worse, in my opinion, is the possibility that because we’re focusing so much on Shaken Baby Syndrome as the definitive form of child abuse that we’re missing out on helping families where abuse is a real problem. You can’t stop child abuse simply by telling people not shake a baby.  To me, this is a reminder of how we need more than good intentions in the field of public health, we need to be brutally honest with ourselves about how we are allocating our resources and what we are supporting so that we can be more effective.